By G. W. COTTIS, M.D., President, Medical Society of the State of New York

Delivered before the Second District Branch Medical Society, Garden City, L. I., October 28, 1942

Vital Speeches of the Day, Vol. IX, pp. 89-91.

AS a nation we are beginning to appreciate the tremendous cost of our unpreparedness to meet what was plainly inevitable. As a profession we should profit by that experience and make sure that we know what is happening or is about to happen to us.

First of all we must realize that the world revolution is not a revolution in the ordinary sense but a fundamental change in social organization. The "New Order" of the Nazis and Japs, the Russian experiment, the Swedish "Middle Way" and the American New Deal are all a part of a tidal wave sweeping irresistibly in one direction. That direction is toward a new form of society in which independence is replaced by dependence and freedom traded for security. The people demand assurance of shelter, food, clothing, recreation and medical care, without much regard to their ability to earn them. The leaders who promise these are the ones the people follow.

Now where do we as a profession fit into the picture? What are the demands of our changing social organization?

What portion of an individual's welfare is to be the concern of the State and what part is to be left to personal initiative?

What shall be the relation of organized medicine to the State and to the public?

What are the defects in our present system of medical care?

What changes or innovations are necessary to provide the highest standards of health for our people?

What is to be our own procedure in the circumstances? Are we to dig in our heels and pull against the trend, or are we to set the objectives and assert and prove our right to leadership?

Medicine has never been entirely static, but her leaders have too often been so. Even in purely medical matters they have bitterly opposed progress. We have only to recall the persecution of Semmelweiss when he proclaimed the infectious cause of child-bed fever, the opposition to Harvey with the circulation of the blood and to Lister with antisepsis. We blush to recall that five years after Valentine Mott used ether to mitigate the horrors of a surgical operation the New York Academy of Medicine made him publicly apologize and promise never to do so again.

On first thought this age long spirit of ultra conservatism seems to have vanished. In the reception of new scientific discoveries we may even suspect that the trend is in the opposite direction. We not only welcome new discoveries andnew technics; we embrace them before their value has been proved. Nevertheless the congenital conservative is still with us. He opposed the growth of scientific medicine, not because it was scientific, but because it was new. Once it was established, he was for it. The new things today, the previously accepted conditions which are rapidly changing, are sociological and political. The swiftness of the change is in itself a challenge to every conservative instinct. The conservative has not ceased to fight for the status quo. He has only found a new adversary. And he has not changed his weapons. Slogans and taboos are his armament both of offense and defense.

I would not liquidate the conservatives any more than I would abolish the brakes on my automobile. Both are necessary to prevent our dashing headlong down hill. But when we are struggling on an upgrade of difficult problems we must not be halted by any slogan waved like a red flag before our eyes.

We cannot hold back the stream of world-wide changes by standing pat. If we are to escape regimentation we must prove that we ourselves can and will meet every legitimate demand for service in the field of medicine. If we fail to do so, there is no doubt that our State and Federal governments will. We have reason to believe that the machinery is already set up and ready to function. The handwriting is on the wall. It is time to act.

It is hard for us to understand why it is that for many years we have been on the defensive, attacked not only by quacks and charlatans but by the Federal government itself. It cannot be because of our failure to give a high quality of service. We have given our people the lowest death rate and the highest standard of health in the world. I suggest that the chief reason is that we offer services so valuable that people cannot afford to buy them. How can we sell a twelve cylinder standard of service to a man who can scarcely afford a bicycle?

When medicine was more of an art than a science, most of what the doctor had to offer was carried in his little black bag and in the accumulated experiences stored in his brain. His investment in education and in equipment was so small that he could afford to sell at a price so low that all but the very poor could buy his goods, and the very poor were treated gratis in accordance with age-old traditions.

Today we can offer benefits arising from an expansion of scientific knowledge so vast and so rapid that few people can visualize it. Among them are immunization againstinfectious diseases, x-rays for diagnosis and treatment, pathological and bacteriological diagnosis, serological tests, hormone therapy, revolutionary new forms of treatment for fractures, and the amazing development of new surgical technics.

It is the full benefit of all these modern implements that the public demands. The Fortune poll last summer showed that the majority of all classes of people favored taxation to provide necessary medical care to all the people regardless of their ability to pay. The very rich need not concern us because they can afford to buy whatever services they need and also because it seems likely that they will soon be liquidated as a matter of government policy. The very poor are receiving medical care whose quality varies widely in different sections of the country. You are all familiar with the proposal made this year that the Federal tax for Social Security be raised to include free medical care to all recipients of Social Security benefits. If this proposal is put into effect, it will mean a staggering burden of taxation on workers and employers alike. The Elliott Bill provides an initial tax of 5 per cent of each worker's salary plus 5 per cent to be paid by his employer. What part of the revenues derived from this taxation would go to the support of the bureaucrats and what part would finally reach the recipients of the promised relief is anybody's guess. We are told that in other countries having socialized medicine there are two lay employees for every doctor rendering service to the sick.

There are few if any communities in this country which cannot afford to provide adequate medical service to its medically indigent people through local taxation. Such a system is more efficient because the local authorities are better acquainted with local conditions than any federal administrator could be and there can be no doubt that the cost of administration would be infinitely less. In the years of the depression many plans were evolved and tested in all parts of the country. With the experience gained by these experiments it should be possible to formulate and promote a system which would meet all reasonable demands.

The problem of bringing to the great middle class all of the benefits of medical science is a more difficult one. It is probable that the high cost of such services could be borne by the average wage earner or salaried employee if the cost could be spread by some form of insurance. The advocates of compulsory health insurance use this argument and they are becoming constantly more vociferous. If compulsory health insurance ever becomes necessary, it will be because of the difficulty of selling insurance on a voluntary basis. The Medical Society of the State of New York is now working hard to promote voluntary sick indemnity insurance through non-profit agencies. It has endorsed three different organizations, one in Brooklyn, one in Utica and one in Buffalo. Although still in the experimental stage these organizations have already proven the practicability of the method.

Hospitalization insurance has proven its value and the number of people insured under this plan is increasing by leaps and bounds. It is important that the people be made conscious of the necessity for a similar plan of insurance against sickness but this can be done only if and when the doctors of this state are themselves sold on the proposition. Insurance salesmen can be employed but they will be successful only when the family doctor endorses the plan to his patients.

If voluntary non-profit insurance fails, what then? The men in control at Washington say compulsory insurance. That is revolution. We prefer evolution, and we justify our faith by the progress already achieved by normal evolutionary processes. The end results of any revolution are unpredictable. The forward course of evolution can be predicted by looking backward. Let us try the experiment.

Sixty years ago all doctors rendered services of the same kind. The only differences were those of training and ability. Even those giants whom we look upon as the fathers of modern surgery were general practitioners. Not one of them confined his work to surgery. Specialties did not exist. Preventive medicine and public health services as we understand them were rudimentary. What has happened in a half century is a perfect fulfillment of Herbert Spencer's famous definition of Evolution. Without quoting it in full I shall remind you only of two significant words: Integration and heterogeneity. From a homogeneous mass of similar practitioners we have become integrated into a great number of groups of heterogeneous specialists.

It should be possible to project these continuing changes into the future. Specialists are more and more to be specialists by training instead of by self-acclaim. The various American Boards of Examiners are proof of that. Even the forgotten man of medicine, the general practitioner, is becoming recognized as a sort of super-specialist, functioning like the controller of a great railroad center, able to start his charges on the right track.

Hospitals follow the same law. As they grow larger they develop more departments or services, each of which becomes a more or less independent unit with its own function to perform. The hospital has evolved from a unicellular organism to a multicellular one with separate organs for the performance of many different duties. Homogeneity is replaced by heterogeneity.

Our next step is to consider the state itself as an organism. Medicine is one of its vital organs and as an organ its functions (and therefore its structure) becomes increasingly more complex. These functions at present are prevention, diagnosis and cure. They are constantly becoming more interdependent.

Twenty-five years ago public health activities were concerned largely with sanitation, food and water supplies and quarantines. Today we depend on the State Department of Health for the laboratory diagnosis of diphtheria, typhoid, undulant fever, tuberculosis and many other diseases. We use without much thought of State medicine the free vaccines and antitoxins provided without charge by the State. We are grateful for such institutions as the State Institute for the Study of Malignant Disease which provides us with free tissue diagnosis and gives our cancer patients radiotherapy otherwise unobtainable. We send our patients to state-provided mental and orthopedic diagnostic clinics. We accept as a matter of course the treatment furnished by hospitals for the insane and county tuberculosis hospitals.

What has all this to do with compulsory health insurance and socialized medicine? To my mind the evolution of state aid as I have tried to sketch it points the way to the solution of our problem. Instead of a bureaucratic political control of medical practice, with all the inefficiency, waste and overwhelming administrative expense of such a system let the State supply us with what is necessary to lower the costs of medical service. The aids which I have enumerated have not in any way interfered with our freedom of action. On the contrary they have proven of such value that we would not wish to have them discontinued.

The greatest single complaint in the matter of medical expense is that of the high cost of diagnosis. If evolution is permitted to follow the trend of the past quarter-century there will be a continuous expansion of the diagnostic facilities furnished to our patients at State expense. By such aprogram the costs of medical care can be reduced at a price infinitesimal as compared with compulsory health insurance, and without interference with our traditional American way of life.

State aid is not state medicine. It is a substitute for it. We are already so dependent upon it that its withdrawal now would be a calamity. Whether or not our plans for voluntary sick indemnity insurance succeed, the popular demand for medical care at lower costs can be met only by some form of subsidy by the state. It is for us to study the question and decide the most effective way that such a subsidy can be used.

As a first step I suggest an extension of medical service by the State of New York in the following ways:

1. Many more hospitals for the care of cancer patients.

2. Extension of laboratory facilities, without cost to patients, in every county.

3. Provision of diagnostic clinics in general medicine similar to those now in operation for orthopedics and mental diseases. Such clinics to be open only to patients referred by a physician.

4. Convalescent homes to reduce the cost of care for patients with chronic diseases, who do not require the more expensive services of a general hospital. This would not only reduce costs for the patient, but would relieve the hospitals of a burden which is both serious and unjustified.

5. Organization throughout the state of district or county health units with full time commissioners and adequate personnel of nurses and technicians. This is of especial importance during the war when every means to prevent illness lessens the demand for curative treatment by the overworked practitioners left at home.

In the care of low income farmers, the Farm Security Administration has cooperated with county medical societies in furnishing medical services. This experiment has proven the feasibility of teamwork by government agencies and organized medicine. It indicates that the medical profession can work with government agencies without surrendering its own freedom of action or lowering its standards of service. It may evolve into a system which will be applied to all groups of medically indigent people. It may avert the evils of state medicine.

I know that these suggestions are not the answer to our many problems. I bring them to you in the hope that they may stimulate thought and bring some hint of the changes that surely will come.

"The old order changeth, yielding place to new." It is not a good time to shut our eyes. Neither is it a good time for pessimism or defeatism. We alone have the knowledge necessary to decide the direction of change in all matters of health. We also have the power if we act intelligently and unitedly. It is time for us to pass from the defensive to the aggressive. The zero hour is here. Let us leave our trenches, set our own objectives and press onward to our goal.